Basic Information
| Provider Information | |||||||||
| NPI: | 1174553465 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PITTMAN | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | DENISE | ||||||||
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| Credential: | MSN, ACNP, RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9722342987 | ||||||||
| Practice Location | |||||||||
| Address1: | 506 W WINDCREST ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786244639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8309900255 | ||||||||
| FaxNumber: | 8309977569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 541246 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 8Y0398 | 01 | TX | BCBS | OTHER | 335303902 | 05 | TX | MEDICAID |